Arizona Integrative Medical Solutions 4657 S. Lakeshore Dr, Ste #1 Tempe, AZ
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1 Arizona Integrative Medical Solutions 4657 S. Lakeshore Dr, Ste #1 Tempe, AZ Diabetic Health History Patient Name: Date: DOB: Age: Street Address: City: State: Zip: Home phone: Work Phone: Cell Phone: Pharmacy Name, Address, Phone: Highest level of education: Occupation: Employer Hours work per week: Marital Status (circle): Single Married Partner Separated Divorced Widowed Insurance Company: Policy: Group #: Name of Insured: Relation to Insured: Does your insurance cover LabCorp or Sonora Quest?: Person to call in case of Emergency: Relationship to you: Phone number for emergency contact: Previous/Current Physician and City: How did you hear of the clinic? Please list any Additional Questions or Expectations of your visit today: Diagnosis/Labs What type of diabetes do you have: Do you have a family history of diabetes When were you diagnosed with diabetes: Please list out any other medical conditions you have: When was your last blood work: On average, what is your typical A1C: Are there any other labs that are problematic regularly: What type of glucose meter do you use: How many times a day and when during the day (fasting, after lunch, etc.) do you check your blood sugars:
2 Do you have any diabetic complications? (Nerve, Eyes, Kidneys, Cardiovascular disease): When was your last diabetic eye exam? Do you check your feet daily? List All Surgeries and Hospitalizations: 1. Date: 2. Date: 3. Date: 4. Date: 5. Date: List All Accidents, Injuries, Physical Traumas: 1. Date: 2. Date: 3. Date: Please Note When and Why You Had Each of The Following: X-rays: MRI/Cat Scans: Ultrasounds: Please give full name, dosage, how often and how long you have taken each medicine/supplement. Pharmaceuticals Dose When/How Often When Started If you are taking insulin please answer the following questions (If not, please skip to supplements below): Are you using vials/syringes, pens, pump:
3 What is your typical dose of insulin, when you inject? Where do you tend to inject insulin? Have you had any serious hypoglycemia events: Do you have lows and highs regularly with your glucose levels: How do you treat hypoglycemia: Do you have hypoglycemic unawareness? Do you have a diabetic ID and if so, do you wear it regularly? Do you have a glucagon kit? Have you ever needed to use it? How do you measure ketones and when was the last time you needed to do so? Supplements Dose When/How Often How Long Please List All Sensitivities/Allergies/Reactions Drugs: Foods: Environment: Did you have the following Disease (D), Get Immunized for it (I), or Neither (N): Measles: D I N Diptheria: D I N Mumps: D I N Tetanus: D I N Rubella: D I N Whooping Cough: D I N Chickenpox: D I N Hemophilus (Hib): D I N Hepatitis B: D I N German Measles: D I N Polio: D I N
4 Any vaccination reactions: List Yes, No, or Past regarding use of the following: Antacids: Y N P Steroids: Y N P Smoking: Y N P Packs per day if Yes/Past: Analgesics: Y N P Laxatives: Y N P Coffee: Y N P Cups per day if Yes/Past: Soda Pop: Y N P Ounces per day if Yes/Past: Alcohol: Y N P How often and how much if Yes/Past: Any alcohol addiction: Y N P Any alcohol treatment: Y N P Recreational drugs: Y N P Any drugs addiction: Y N P Any drug treatment: Y N P Family history Father Mother Siblings Grandparents Spouse Children Age if living Age when died Reason for death Cancer (type) Y N Y N Y N Y N Y N Y N High Blood Pressure Y N Y N Y N Y N Y N Y N Heart Attack/stroke Y N Y N Y N Y N Y N Y N Heart disease Y N Y N Y N Y N Y N Y N Asthma/allergies Y N Y N Y N Y N Y N Y N Mental illness Y N Y N Y N Y N Y N Y N Addiction Y N Y N Y N Y N Y N Y N TB Y N Y N Y N Y N Y N Y N Auto-immune Y N Y N Y N Y N Y N Y N Diabetes Mellitus Y N Y N Y N Y N Y N Y N Osteoporosis Y N Y N Y N Y N Y N Y N Any other conditions: Review of Systems: Present Weight: Height: Max Height: Maximum Weight and when: Minimum Weight and when: Weight one year ago: Ideal Weight: History of weight loss/weight regain dieting?
5 REGARDING THE NEXT SECTION: Please Circle Y if you have the problem NOW, N if you ve NEVER had the problem, P if you had the problem in the PAST. The general state of your health is: Excellent Good Average Fair Poor On average describe your energy level from 1 (low)-10: (high) If you have fatigue, when is it the worst: morning, afternoon, evening? If you have fatigue, can you do what you need to during the day? Y N Skin: Rash/hives: Y N P Color Change: Y N P Acanthrosis Nigracans : Y N P Lump: Y N P Psoriasis/eczema: Y N P Itchy: Y N P Dry: Y N P Warts/moles: Y N P Cancer: Y N P Perspiration: Y N P Head: Headache: Y N P Migraine: Y N P Dandruff: Y N P Head Injury: Y N P Oil/dry hair: Y N P Hair loss: Y N P Eyes: Dry/Watery: Y N P Glaucoma: Y N P Vision changes: Y N P Cataracts: Y N P Styes: Y N P Macular Degeneration: Y N P Strain: Y N P Discharge: Y N P Itchy: Y N P Dark under eyelid: Y N P Ears: Infections: Y N P Ear Wax: Y N P Hearing Loss: Y N P Tinnitus: Y N P Nose: Frequent colds: Y N P Nosebleeds: Y N P Congestion: Y N P Post nasal drip: Y N P Polyps: Y N P Seasonal allergies: Y N P Mouth/Throat: Canker sores: Y N P Sore throat: Y N P Cold sores: Y N P Hoarseness: Y N P Dentures: Y N P Cavities: Y N P Loss of taste: Y N P Gingivitis/Periodontal Disease: Y N P How often you do you brush your teeth? Floss? What type of brush do you use? How often do you go to the Dentist?
6 Neck: Stiffness: Y N P Swollen glands: Y N P Full movement: Y N P Tension: Y N P Respiratory: Cough: Y N P TB: Y N P Wheezing: Y N P Painful breathing: Y N P Shortness of breath with exertion: Y N P Bronchitis: Y N P Shortness of breath sitting: Y N P Pneumonia: Y N P Shortness of breath lying down: Y N P Asthma: Y N P Cardiovascular: High blood pressure: Y N P Rheumatic Fever: Y N P Low blood pressure: Y N P Murmurs: Y N P Arrhythmias: Y N P Palpitations: Y N P Edema: Y N P Chest pain: Y N P Gastrointestinal: Heartburn: Y N P Bowel movement frequency: Indigestion: Y N P Recent change in BM: Y N P Bloating: Y N P Diarrhea or constipation: Y N P Nausea: Y N P Hemorrhoids: Y N P Vomiting: Y N P Gall bladder disease: Y N P Change in Appetite: Y N P Liver disease: Y N P Pancreatitis: Y N P Ulcer: Y N P List all travel outside the US over the last five years: Have you ever had food poisoning? Have you noticed any of the below in your stool or toilet bowl or on toilet paper? Blood Mucus Undigested Food Black Stool Lighter colored stool How many antibiotics have you had in your entire life? If you are over 50 y/o, when was your last colonoscopy? Urinary Tract: Incontinence: Y N P Pain/burning with urination: Y N P Frequent infections: Y N P Kidney stones: Y N P Urgency: Y N P Discharge/blood: Y N P Female Reproductive: IF MALE, PLEASE SKIP Times Pregnant: Births Miscarriages Abortions Difficulty Getting Pregnant? Do you do a Self Breast exam regularly? Y N How often?
7 Any breast tenderness, lumps, nipple discharge? Age periods began: How often periods occur? How long does the period last? If Menopausal, at what age did it begin? Any problematic menopausal symptoms? If yes, how were/are they treated? Periods: Heavy Bleeding: Y N P Clotting: Y N P Cramping: Y N P Pain: Y N P PMS: Y N P Food Cravings: Y N P Bloating: Y N P Irritability: Y N P Breast tenderness: Y N P Last Pap Smear: Any abnormal paps? Y N P Date if Yes : How was that treated? Paps showed HPV negative: Y N Unknown Mammography: Last Time: Any Concern: Dexa Bone Scan: Last Time: Any Bone Loss Use of Hormones Y N P If Yes which ones and for What purpose: Are you still on any hormones: Sexual History: Sexual Orientation: Heterosexual Homosexual Bi-Sexual Asexual Sexually Active: Y N P Healthy Libido: Y N P Sexually Satisfied: Y N P Painful Intercourse: Y N P Sexually Transmitted Infection: Y N P If yes, please list: What methods of birth control or safe sex practices are you currently using or interested in using? Male Reproductive: IF FEMALE, PLEASE SKIP Prostate: If over 40, Date of Last Prostate Exam and PSA Blood Work: Problems Starting Urination Y N P Urination Voiding: Always Complete Mostly Complete Usually Incomplete
8 Dribbling After Urination: Y N P BBP/Enlarged Prostate: Y N P Prostatitis: Y N P Penile/Scrotal Skin Rash: Y N P Testicular Pain/Swelling: Y N P Hernia: Y N P Penile Discharge: Y N P Pain/Burning on Urination: Y N P Sexual Function: Mark any that is positive Difficulty Achieving Erection: Difficulty Maintaining Erection: Premature Ejaculation: Waking Erection Regularly: Performance Anxiety: Concerns of Low Testosterone: Sexual Orientation: Heterosexual Homosexual Bi-Sexual Other: Method of birth control or safe sex practices are you currently using? Sexually Active: Y N P Healthy Libido: Y N P Sexually Satisfied: Y N P Sexually Transmitted Infection: Y N P If yes or past please list: Musculoskeletal: Weakness: Y N P Arthritis: Y N P Stiffness: Y N P Leg cramps: Y N P Tremors: Y N P Pain: Y N P Nervous: Paralysis: Y N P Sciatica: Y N P Tingling/numbness: Y N P Carpal tunnel: Y N P Seizures: Y N P Fainting: Y N P TMJ Syndrome: Y N P Disc Disease: Y N P Mental/Emotional: Which words best describe you? Lacking Dreams Without passion or purpose Anticipate Failure Isolated/Lonely Lacking Self Worth Overly Responsible Difficulty Letting Go Lacking Faith Overly Controlling Guilty Judgmental Self-Critical Frustrated/Angry Impatient Indecisive/No Confidence Lacking Trust Neurotic/Obsessive Anxious
9 In A Rush Abuse Victim Memory Problems Exercise: Do you have any equipment at home? Do you belong to a gym? What is your history of exercising throughout your life? Always Active Active On/Off What types? How many days a week? How long a session? Hobbies: Sleep: How many hours per night: How long does it take you to get to sleep? Do you sleep through the night uninterrupted? Y N If you wake up regularly, what is the reason? Nightmares: Y N P Wake Refreshed: Y N Why not: Grinds Teeth: Y N P Sleepwalk: Y N Snores: Y N Apnea: Y N Unknown Never Active If you have been diagnosed with sleep apnea how are you treating it? Nap During Day: Wants To But Can t Do Not Need To Does Nap At This Time Usually Food: Appetite Good? Y N P Do you have constant hunger or do not feel full easily or hungry again soon after eating? Y N Foods you crave? Foods you dislike? Foods that don t sit well? If on rapid/regular insulin for meals, do you inject 15 minutes before meals? Y N N/A Toxin Exposure: Where were you born/lived in life? Did you grow up near any refinery, or polluted area, or in home with leaded paint? If so, what sort of pollution were you exposed to? Have you had any jobs where you were exposed to solvents, heavy metals, fumes, or other toxic materials? Have you ever had health problems when you put in new carpeting, painted your home, new cabinets, or did other refurbishing? Are you particularly sensitive to perfumes, gasoline, or other vapors? Do you use pesticides, herbicides, other chemicals around your home?
10 Home Life: Active Spiritual practice: Y N P How Happy are you with the direction of your life (1 not happy-10 Very happy)? Do you have a good support network of family/friends? Most Significant Relationship: Healthy/Excellent Unhealthy/Abusive If abusive, list how: Emotional Physical Other If you have children, good relationship? Do you enjoy your work? How many hours do you work a week? What do you do for fun /stress release? How committed are you towards making valuable changes: Somewhat Moderately Very
Arizona Integrative Medical Solutions 4657 S. Lakeshore Dr, Ste #1 Tempe, AZ
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